View Full Version : Evaluation of the patient with acute extremity ischemia

14-10-10, 12:44 AM
A thorough history and physical examination is the first step in the evaluation of the patient with acute extremity ischemia [6]. The five "P's" of acute ischemia are:

• Pain
• Pallor
• Paresthesias
• Pulselessness
• Paralysis

Pain — Pain associated with acute ischemia is usually located distally in the extremity, gradually increases in severity, and progresses proximally as the length of ischemia increases. Later, the pain may decrease in severity due to progressive ischemic sensory loss.

It is essential to determine if the patient had symptoms of chronic ischemia before the acute event occurred. Patients with an embolus usually have no preexisting ischemic symptoms, and can frequently pinpoint the exact time that symptoms began. Thus, the sudden and dramatic development of ischemic symptoms in a previously asymptomatic patient is most consistent with an embolus, while gradually increasing symptoms in a patient with chronic ischemia is indicative of thrombosis.

Pulse — The quality and character of the peripheral pulses must be evaluated. If pulses are not palpable, a hand held Doppler should be used. It is rare to have limb threatening ischemia without a major pulse deficit.

The status of the pulses in the contralateral extremity is also important. The presence of a pulse deficit in an asymptomatic contralateral extremity is an indication of underlying chronic arterial occlusive disease and suggests that acute thrombosis of an already diseased vessel is the most likely cause of the acute occlusion. By contrast, the presence of normal pulses in the contralateral extremity suggests the absence of chronic occlusive disease, and increases the likelihood that an embolus is the etiology of acute occlusion.

Skin — The skin of both the normal and affected extremity should be examined for temperature, color, and capillary refill. The skin of the ischemic extremity is typically cool and pale with delayed capillary filling. The level of arterial obstruction is usually one joint above the line of demarcation between the normal and ischemic tissue. Both extremities should also be examined for signs of chronic ischemia such as atrophy of the skin, hair loss, and thickened nails.

Neurologic examination — A careful neurologic examination must be performed. Subjective sensory deficits such as numbness or paresthesias are signs of early nerve dysfunction secondary to ischemia. Major loss of sensory or motor function is indicative of advanced ischemia. The anterior compartment of the lower leg is most sensitive to ischemia, and sensory deficits over the dorsum of the foot are often the earliest neurologic sign of vascular insufficiency

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